A New Understanding of Identity in a Gender Creative World
DR DIANE EHRENSAFT DR MICHELLE JURKIEWICZ
GENDER EXPLAINED
“The authors thoughtfully examine how and why gender has become a pressing concern for today’s youth. . . . A thorough, evenhanded illumination of a contentious topic imbued with compassion and cleareyed data.”—
KIRKUS REVIEWS
“This is the book I wish I’d had when my own child told me, at age three, that she wasn’t the gender I believed her to be. If you’re scared and confused because your child is saying things about gender that you never expected to hear, this is the book for you. Gender Explained sets aside the politics, lays out the science, and offers practical, compassionate advice for supporting our children—and ourselves—on the gender adventure that awaits us.”
—MARLO MACK, author of How to Be a Girl
“Gender Explained is the perfect antidote to the current state of widespread confusion about gender. Ehrensaft and Jurkiewicz’s careful, thoughtful, and well-researched approach to the topic of gender cuts through a sea of misinformation. In this widely accessible book, the authors help us make sense of the complexity of gender. They also lay the groundwork for a clear path forward to understanding and celebrating gender in all its infinite forms.”
—SABRA L. KATZ-WISE, PhD, associate professor at Boston Children’s Hospital, Harvard Medical School, and the Harvard T. H. Chan School of Public Health
“In Gender Explained, Ehrensaft and Jurkiewicz have taken a hot button issue and eloquently turned down the heat. Their extensive experience working with youth, families, and professionals throughout the world provides them with the necessary background to examine this divisive topic with nuance and rationality. In doing so, they have generated a work upon which critically important conversations can be based at a time when the discourse has become decidedly hostile. A must-read for anyone interested in exploring the complex subject of gender.”
—JOEL BAUM , director of education at the Child and Adolescent Gender Center, UCSF Benio Children’s Hospital
“The continent’s greatest clinical psychologist, Diane Ehrensaft, PhD, working in pediatric gender issues in an academic research setting, has added to her two previous groundbreaking books, now with colleague Michelle Jurkiewicz, PsyD. Gender Explained reveals how our thinking about gender has changed through the lens and voices of patients, parents, and those who care for gender creative children. In addition to their clinical expertise, Dr. Ehrensaft also draws on her participation in two NIH-funded longitudinal studies of transgender children and adolescents, in collaboration with three other major pediatric academic hospitals.”
—NORMAN SPACK, MD, endocrinologist at Boston Children’s Hospital
“With courage and wisdom, this book does an amazing job at explaining gender diversity. It brings together empirical research, clinical experience as well as testimonies of children and their parents to answer complicated questions about child and identity development, best parenting approaches and how to understand today’s shifting cultural landscape on gender and young people. A highly recommended read for families, clinicians, and anyone eager to better understand our complex world.”
—JEAN MALPAS, psychotherapist and founder of the Gender & Family Project at the Ackerman Institute for the Family
“Empathetic and accessible, Gender Explained helped me see ‘the other side’ of the gender debate. It acknowledges the fear and concern that many people face and helps us expand our view of gender. I loved reading it.”
—XIMENA LOPEZ, MD, pediatric endocrinologist
“At a time when there is a lot of divisive information and messages on this topic, Gender Explained unites us in supporting the health and well-being of all children. Dr. Ehrensaft and Dr. Jurkiewicz provide clear and compassionate information from decades of fi rsthand experience. Th is is the perfect book for parents, caregivers, and professionals who are supporting gender expansive children and youth.”
—LINDA A. HAWKINS, PhD,
director of the Gender & Sexuality Development Program at Children’s Hospital of Philadelphia
“A compelling new book rooted in the gender affirmative model, Gender Explained provides a nuanced perspective and eff ectively clarifies some deep misrepresentations of this model. It provides a wealth of information on the care of gender diverse young people.”
—AMY TISHELMAN, PhD, Boston College, Department of Psychology and Neuroscience
GENDER EXPLAINED
Also by Dr Diane Ehrensaft
e Gender Creative Child: Pathways for Nurturing and Supporting Children Who Live Outside Gender Boxes
Gender Born, Gender Made: Raising Healthy Gender-Nonconforming Children
Mommies, Daddies, Donors, Surrogates: Answering Tough Questions and Building Strong Families
Spoiling Childhood: How Well-Meaning Parents are Giving Children Too Much— But Not What ey Need
Parenting Together: Men and Women Sharing the Care of their Children
A New Understanding of Identity in a Gender Creative World
A New Understanding of Identity in a Gender Creative World
E X P A N E D
DR DIANE EHRENSAFT
DR MICHELLE JURKIEWICZ G E N D E R
G E N D E R E X P A N E D
DR DIANE EHRENSAFT
DR MICHELLE JURKIEWICZ
Vermilion, an imprint of Ebury Publishing 20 Vauxhall Bridge Road
London SW1V 2SA
Vermilion is part of the Penguin Random House group of companies whose addresses can be found at global.penguinrandomhouse.com
Diane Ehrensaft and Michelle Jurkiewicz have asserted their right to be identified as the authors of this Work in accordance with the Copyright, Designs and Patents Act 1988
First published in Great Britain by Vermilion in 2024 First published in the United States of America by The Experiment, LLC in 2024
This book contains the opinions and ideas of its author. It is intended to provide helpful and informative material on the subjects addressed in the book. It is sold with the understanding that the author and publisher are not engaged in rendering medical, health, or any other kind of personal professional services in the book. The author and publisher specifically disclaim all responsibility for any liability, loss, or risk – personal or otherwise – that is incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this book.
www.penguin.co.uk
A CIP catalogue record for this book is available from the British Library
ISBN 9781785045240
Printed and bound in Great Britain by Clays Ltd, Elcograf S.p.A.
The authorised representative in the EEA is Penguin Random House Ireland, Morrison Chambers, 32 Nassau Street, Dublin D02 YH68
Penguin Random House is committed to a sustainable future for our business, our readers and our planet. This book is made from Forest Stewardship Council® certified paper.
To all the gender creative children and parents who have taught us so well
Foreword by
Stephen M. Rosenthal, MD
Foreword
by Stephen M. Rosenthal
While gender was once primarily in the domain of psychologists and social scientists, it has found its way into mainstream consciousness. But what is gender, and why, in recent years has it become associated with emotionally charged and heated debate, often landing in the crosshairs of a culture war? This book by Diane Ehrensaft, PhD, and Michelle Jurkiewicz, PsyD, truly lives up to its title, Gender Explained:
A New Understanding of Identity in a Gender Creative World.
Gender identity, a person’s inner sense of self as male, female, or somewhere on the gender spectrum, is typically aligned with a person’s sex—the physical or genetic attributes that characterize biological maleness or femaleness; for example, external and internal genital structures, gonads, and sex chromosomes. However, gender and sex are not always aligned, and individuals have demonstrated gender diversity throughout history. The reality that a person’s sex and gender can be different has spawned the concept of gender-affirming care, based on the belief that every person is entitled to live in the gender that is most authentic to them, and in a manner that honors a person’s individuality and promotes their well-being. What is this care, and why is it so controversial?
While not every gender-diverse person seeks medical and/or surgical treatments to bring their physical sex characteristics into alignment with their gender identity, recent years have borne witness to an increasing number of transgender and gender-diverse youth seeking
gender-affirming care—an approach that was pioneered in the Netherlands and that only emerged in the late twentieth century.
Through the lens of developmental psychology, Dr. Ehrensaft, an internationally recognized expert in child and adolescent gender care, and her colleague, Dr. Jurkiewicz, carefully guide us on a journey to fully understand gender itself and gender-affirming care. This guidance is remarkably accessible and engaging, as if the authors are speaking directly to you—whether you are a parent/caregiver, client, or provider, or simply a person who wants to learn. The authors address core issues about medical interventions, including puberty blockers, gender-affirming sex hormones, and gender-affirming surgeries—explaining when such treatment is indicated and when it is not—and they thoughtfully tackle every major gender-related controversy of our time: Why the exponential increase in youth referrals to gender clinics, globally, in recent years? Why the increase in gender-diverse adolescents designated female at birth? When do youth know their gender? What is the state of research for gender-affirming care for adolescents; what are the risks and benefits of such care; what are the gaps in our knowledge; and what are the barriers to such care? Why the controversy surrounding sports—in particular, participation of transgender girls in girls’ sports—and how to think about the challenges in prioritizing inclusion as well as fairness? What are the complexities involved in these considerations? And what about retransition, discontinuation of care, and regret?
In a refreshing and inspiring style, this book teaches us about “gender literacy,” making the compelling case that learning about gender is lifelong, and that gender is not necessarily fixed at any age, but may, in some, evolve over a lifetime. With the aim of promoting gender health for all—not just adolescents—the authors emphasize the importance of “listening, not telling,” and by their own examples, they provide guidance on strategies to promote your own self-reflection to enhance your gender literacy. Despite the controversies, we live in a time of evolving research and increased understanding that will be key to optimizing gender-affirming care. Gender Explained challenges us to imagine a time when “gender in all its splendor is just a fact of life.”
Stephen M. Rosenthal is cofounder and medical director of the multidisciplinary UCSF Child and Adolescent Gender Center (CAGC), where he cares for young transgender clients. He also cares for pediatric clients with endocrine disorders, such as abnormalities involving thyroid function or growth and puberty. Dr. Rosenthal is one of four principal investigators for the Impact of Early Medical Treatment in Transgender Youth, a multicenter study sponsored by the National Institutes of Health and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. He is currently a member of the board of directors of the World Professional Association for Transgender Health.
Glossary
Cisgender: A person whose sex designated at birth matches their gender identity.
DFAB: An abbreviated term for “designated female at birth,” previously known as “assigned female at birth” (AFAB), referring to a person who is perceived as female at birth.
DMAB: An abbreviated term for “designated male at birth,” previously known as “assigned male at birth” (AMAB), referring to a person who is perceived as male at birth.
GAHT (gender-a rming hormone treatment): A medical treatment that provides a person with hormones (i.e., estrogen or testosterone) to treat dysphoria and to align their body more closely with their gender identity.
Gender Creativity: The psychological process by which each individual consolidates their unique gender self, based on nature, nurture, and culture.
Gender Diverse: Used to describe any person who identifies as or expresses their gender in ways that are outside of conventional norms. Some examples include a cisgender man who wears nail polish and long hair or a nonbinary person who presents as androgynous.
Gender Dysphoria: Distress or discomfort that may occur for some people whose gender identity does not match their sex designated at birth.
Gender Expressions: The ways in which a person expresses their gender, such as through clothing, hairstyles, and mannerisms.
Gender Identity: Refers to the gender that a person identifies with. This identity may match their sex designated at birth (i.e., cisgender) or may not match their sex designated at birth (i.e., transgender).
Gender Minority Stress: High levels of stress faced by transgender and gender-diverse people as the result of various social and structural factors, such as poor social support and discrimination.
Gender Noise: Constant thoughts, feelings, or worries about one’s gender and how other people are experiencing it, sometimes preoccupying a person or distracting them from other activities.
Genderqueer: A gender identity that cannot be categorized into girl/woman or boy/man.
Gonadotropin-Releasing Hormone (GnRH) Agonists: The medical term for puberty blockers, which are medications that stop the body from producing the hormones (i.e., estrogen or testosterone) that cause the physical changes of puberty.
Nonbinary: A variety of gender identities that do not exclusively fit into girl/woman or boy/man. For example, a person might identify as both a girl and a boy or as neither a girl nor a boy.
Puberty Blockers: Common term for GnRH agonists. See above.
Sex Designated at Birth: The sex (male or female) that a person is designated to be based on their genitals at birth.
Sexual Identity: An identity based on who someone is sexually attracted to, often based on the other’s gender identity. Some common sexual identities include heterosexual, gay, lesbian, or bisexual, among others.
Transgender: A person whose gender identity does not match their sex designated at birth.
Transfeminine/Transfemme: Usually a person designated male at birth who identifies as any number of gender identities outside of boy/man, for whom femininity is an important part of their gender identity. For example, someone may identify as nonbinary and transfemme.
Transmasculine/Transmasc: Usually a person designated female at birth who identifies as any number of gender identities outside of girl/woman, for whom masculinity is an important part of their gender identity. For example, someone may identify as nonbinary and transmasc.
Trans Boy/Trans Man: A person who was designated female at birth and identifies as a boy or man.
Trans Girl/Trans Woman: A person who was designated male at birth and identifies as a girl or woman.
Much Ado About Gender
Jenna Karvunidis came up with an idea to celebrate the upcoming birth of her first child, Bianca, born in 2008. She and her husband decided to host an event revealing their baby’s gender to family and friends with a special cake that contained colored icing inside—blue for a boy or pink for a girl. Jenna neither intended nor expected that her gender reveal party idea would take off as it did with party packs sold on Amazon, websites devoted to gender reveal party planning, and gender reveal parties featured on popular TV series. Most of these parties have included simple ways of announcing a baby’s gender, such as the cake filling that Jenna used, or with the release of balloons: pink for “It’s a girl” or blue for “It’s a boy.”
Unfortunately, some of these parties became so extravagant that gender reveal parties gone horribly wrong made many headlines over the years. For example, in 2017, more than forty-five thousand acres in and around Coronado National Forest burned after an expectant father shot a rifle at a target that contained pink or blue explosive powder, which resulted in damages greater than eight million dollars. Another wildfire started by a gender reveal party in 2020 resulted in the death of a firefighter and criminal charges for the expectant parents. Other gender reveal parties made headlines after serious injuries to partygoers, and in fact, there were at least seven deaths in five separate incidences, including a pilot’s death during a gender reveal party stunt in 2023, all in an attempt to celebrate the gender of a child not even born yet.
Over the subsequent years, Jenna had two more children and watched as all of their genders developed. One Christmas morning, her three-year-old middle daughter burst into tears because she thought her Lego set in primary colors was a “boy’s toy” and didn’t have girly-enough colors. Bianca, for whom Jenna had held the one and only gender reveal party, rejected dresses and preferred to wear a suit for their family photo instead.1 These two children had very different gender experiences and expressions even though both identified as girls and were raised in the same family. By 2019, Jenna expressed regret for ever starting the gender reveal party trend. In her own words, she stated, “Who cares what gender the baby is? I did at the time because we didn’t live in 2019 and didn’t know what we know now—that assigning focus on gender at birth leaves out so much of their potential and talents that have nothing to do with what’s between their legs.”2
State of A airs
As Jenna pointed out, a lot has changed about gender in a relatively short time. Hardly a day goes by across media outlets without reference to a gender-related issue, usually about children and adolescents. Should bathrooms be divided by gender, and if so, which bathroom does a transgender person use? What about a nonbinary person? Which sports team does a transgender or gender-diverse child play on? Should educators have to notify parents if a child starts using different pronouns or is going by a new name at school? Is gender diversity allowed to be discussed in schools, or is it too dangerous? And, perhaps most contentious, what is gender-affirming care and should children have access to it? How old should someone be before starting a medical gender transition, such as hormones or gender-affirming surgery? And who should be in charge of answering these questions? Regardless of how you think and feel about gender, whether you celebrate gender variations or fear these changes are leading to the downfall of civilized society, you are thinking about gender.
Research indicates that the number of transgender youth, aged thirteen to seventeen, in the United States doubled between 2017 and 2020 to three hundred thousand, about 1.4 percent of the youth population.3 By 2022, the Pew Research Center reported that 5 percent of young adults in the United States identified as a gender other than the sex on their birth certificate. Approximately 2 percent identified as either a trans man (designated female at birth and identifies as a man) or trans woman (designated male at birth and identifies as a woman). The remaining 3 percent reported a nonbinary identity.4 “Nonbinary” is an umbrella term that can refer to many different experiences of gender identity. Some nonbinary children and youth may identify as feeling like both a boy and a girl, feeling like neither, feeling like sometimes a boy and sometimes a girl, or as something altogether different than boy or girl.
The numbers of transgender and gender-diverse children and teens are reportedly rising, not just in the United States, but around the globe. For example, Latin America as a whole saw the number of transgender people increase by nearly 50 percent between 2008 and 2016.5 The Tavistock Clinic, the only pediatric gender center in England from 2010 to 2015, saw a yearly 50 percent increase of child and adolescent referrals during that time, and then from 2015 to 2016, the referrals doubled.6 Similar numbers were reported in Denmark,7 and during roughly the same time period, Canada reported an increase of ten times the referrals at their gender clinics for children and adolescents.8
In response to the increased numbers of transgender and gender-diverse young people and families seeking support for their children, pediatric interdisciplinary gender programs were established. Most of these gender centers are located in major research hospitals and include an interdisciplinary team made up of pediatricians, endocrinologists, social workers, psychiatrists, and psychologists. Children and their families are helped by an entire team and are provided with comprehensive gender care, including information, medical care, mental health care, and aid in accessing additional services such as educational and legal supports. The number of these clinics continues to grow in
